Modifications of the World Health Organization’s Surgical Safety Checklist—Ways Forward to Ensure Sustainable Implementation
Authors: Arvid Steinar Haugen
Journal: JAMA Network Open (2023)

The study by Brindle and colleagues 1 elsewhere in JAMA Network Open provides novel international perspectives on modifications of the World Health Organization's (WHO) Surgical Safety Checklist (SSC).The article describes opportunities for increasing team members' involvement and ownership through modifications of the checklist.In their qualitative study, semistructured interviews of 51 clinicians and hospital administrators were conducted across 5 high-income countries: Australia, Canada, New Zealand, the United States, and the United Kingdom.Five themes emerged from the data: awareness and involvement in SSC modifications; reasons for modifications; types of modifications; the impact of modifications; and perceived barriers to SSC modifications.Importantly, these findings address contemporary issues in anesthesia and surgery and may hopefully contribute to reinvigorating the SSC as a dynamic and relevant tool for surgical patients' safety.Since the WHO globally introduced the SSC in 2009 as part of the Safe Surgery Saves Lives campaign, 2 it has become mainstream surgical practice to use the checklist.In recent reviews of research literature, there is evidence of SSCs' impact on patient outcomes, 3 reducing both morbidity and mortality when implemented well. 4As the fields of surgery and anesthesia evolve, so does the need to develop the SSC and to adapt it to fit different types of surgery.One example of such development is a consensus statement of stakeholders and experts, where Pilkington and colleagues 5 suggest modifying the SSC to be applied with an existing enhanced recovery after surgery (ERAS) guideline for major surgery, combining the SSC within an ERAS protocol.From the outset, the SSC was intended not to be comprehensive.The WHO encouraged modifications to make it fit local practices, and any alterations made to the checklist should be carried out with care and must involve clinicians, such as surgeons, anesthetists, and nurses, in the modification process. 2 The checklist must focus on the most critical issues, be brief, fit the local flow of care, be actionable on every specific item, promote verbal interaction among team members, support collaboration, and encourage sharing of critical information in the team, according to the WHO implementation guidelines. 2 Brindle and colleagues 1 affirm the emerging evidence on implementation of the checklist, highlighting the modification experiences that clinicians and hospital administrators have had since it was introduced.One of the emerging themes was reasons for specific modifications, which were enacted based on contextual demands and after adverse events occurred.Different types of modifications were identified to make the items fit the flow of care, eg, moving elements between the 3 parts of the checklist or adding an item to a preoperative team huddle (eg, blood loss requirements). 1 The authors also identified that one outcome of modifications was that they improved team members' ownership and engagement in the SSC's use.Finally, they identified some barriers to considering modifications of existing checklists, including institutional barriers to customization, ie, imposing it on team members who were told to adhere, and practicalities around customization of the SSC in electronic systems.This study's findings underline the importance of following the WHO's advice for adaptations of the checklist. 1,2The WHO implementation guidelines emphasize testing changes prior to rolling them out and using local data feedback, simulation, and training as strong drivers for the implementation. 2Sharing of critical information within the team is one of the key points of the checklist.Findings in the study from Brindle and colleagues 1 suggest that one should not remove from the checklist points that empower team communication, briefings, and debriefings.